Country: Lebanon
Closing date: 01 Sep 2017
Seeking Sustainability for Refugee Health Care in Lebanon
TOR for Detailed Health Financing Review and Recommendations
1. Introduction
The Lebanese government together with UN agencies, NGOs and donors are facing the dual challenge of promoting access to health services for both vulnerable Lebanese (estimated 350,000 persons) and Syrian refugees (estimated 1.2 million persons).
There is a critical need to review the provision of health care to vulnerable groups and particularly refugees with a view to seeking sustainable options to guide future endeavours. This is driven largely by the size of the refugee population and the fact that meeting the health care needs of refugees is funded by voluntary humanitarian contributions that are likely to diminish in the years ahead.
2. Context
The health system is largely privatized and relatively high cost. It is characterized by a dominant private sector working on a fee for service basis. Health services are purchased by the Ministry of Public Health (MOPH) from the private sector for around 52% of the population that has no health insurance.
Over 68% of health care expenses are paid by individuals with the remainder covered by private or employer insurance schemes (roughly 15% each). Encouragingly there is an expanding network of state affiliated health service providers, which will increase access to lower cost care. Nevertheless, the fact remains that among Lebanese, the relatively high cost of health services disproportionately negatively impacts the non- insured and economically marginalised.
At the onset of the Syrian refugee crisis efforts were made to integrate refugees within the existing health system.
Primary Health Care
There are around 920 Primary Health Care (PHC) centres which are mostly owned and managed by national NGOs working on a fee for service basis and were in existence before the crisis.
Most humanitarian partners, UNHCR included, cover between 85-100% of costs for refugees. Medicines are mainly provided free of charge but there are some shortages.
UNHCR and several NGOs are currently supporting subsidized access to comprehensive PHC at approximately 130 PHC centres countrywide. Of these 27 are supported through UNHCR’s implementing partners which act as an intermediary directly contracting services from the PHC. Most of these PHCs fall within the Ministry of Public Health (MoPH) affiliated network of 200 PHCs. Services include preventive care such as childhood immunisation, antenatal and postnatal care, family planning, curative care for acute and chronic conditions and mental health care.
Refugees pay a fee of approximately USD 2 per consultation and laboratory tests are subsidised at 85% of the cost for children under five, pregnant women, the elderly and persons with special needs. Vaccination and acute and chronic medicines are available free of charge although shortages of medication have been noted.
From January to December 2016, UNHCR supported a total of 264,465 PHC consultations accounting for approximately 20% of the total consultations supported by humanitarian partners
Secondary and tertiary health care
Most hospitals are privately owned and operated. Just 27 out of the 147 hospitals in Lebanon are government owned but are largely autonomous and function like private institutions.
Referral care hospitalization is highly utilized and expensive. UNHCR has put in place restrictive referral guidelines prioritizing emergency and lifesaving care including obstetrics and covers 75% to 90% of costs depending on socioeconomic vulnerability with the refugees paying the remainder. In some cases humanitarian partners or charities cover the remainder of the fees. Conditions not able to be covered by UNHCR (including high cost chronic conditions, elective surgeries and most cancers) are costly and remain a major unmet need.
UNHCR has contracted a Third Party Administrator to manage the provision of secondary and tertiary health care for refugees through a network of 50 contracted hospitals.
In 2016, there were 73,000 UNHCR supported hospital admissions at a cost of over USD 40 M.
3. Recent Initiatives
MOPH Universal Health Care for Vulnerable Lebanese
The MoPH has launched the Universal Health Care (UHC) project in 2015 targeting subsidised PHC services for 150,000 poorest Lebanese identified by the National Poverty Targeting Programme 9 (NPTP). This was funded by a grant from the World Bank and there is a plan to scale this up in 2018 to reach 350,000 persons through the World Bank Global Concessional Financing Facility (GCFF), a five year project with a USD 150M concessional loan with favourable terms. Approximately three quarters of the loan will be for the scale up of UHC and the other quarter will be for support to government hospitals by increasing the budget for care of uninsured Lebanese and upgrading of equipment. However this project does not include refugees and the current system for provision of access to PHC for refugees through intermediary partners remains fragmented and inefficient.
The UHC project presents a model that could be replicated for refugees, i.e., a single fund and direct contracting of PHC service providers. However, the MoPH has stated that they will not manage the financial aspect of subsidies for refugees so this should be done through a parallel, but closely aligned, system.
UNICEF proposed ‘Thrive’ Child Survival Initiative
UNICEF have recently proposed an initiative named ‘Thrive’ which is a child survival strategy enhancing access to PHC services for pregnant women ( including delivery care) and children under five and WASH activities. The initiative is proposing a reformed pooled financing mechanism (either UN or privately managed fund) and direct contracting of PHC service providers similar to the UHC model. From UNHCR’s perspective, Thrive does not address the comprehensive PHC needs of refugees to include care for those over five years of age, NCD and mental health care.
However, the above initiatives do present an opportunity to expand the package to include the above groups, closely aligned to the UHC model and to establish a more efficient and sustainable financing mechanism.
4. Health insurance schemes
In July 2014 UNHCR undertook a Review of the Potential for Private Health Insurance Scheme for Syrian Refugees in Lebanon. Various models such as group private health insurance (ground base insurance) and stop-loss insurance were explored. It was concluded that considering demographic characteristics, the refugee households’ capacity to pay and peculiarities of the private health insurance including high premiums, the implementation of private health insurance in Lebanon is was not an option but this should be re-examined.
An alternative for managing referral care is a ‘Mutuel’ fund however this would be a privately managed fund which would have an administration cost of at least 15% and less efficient than the current UNHCR system which operates as a self-funded scheme.
Terms of Reference for technical expertise
Under the supervision of the Senior Public Health Officer in UNHCR Lebanon, the health financing expert would conduct a thorough review of the existing system and initiatives and propose the best health financing mechanism for UNHCR to engage in to enhance access to primary and referral care for refugees.
The health expert will consult with the Ministry of Public Health, other UN agencies especially UNICEF and also including WHO, ILO and donors, and national and international NGOs throughout the process.
The scope of a detailed review would include:
Funding and Financing Options for Primary Health Care: detailed assessment of the financing options for provision of subsidised PHC for Syrian refugees within the existing MoPH network. This should build on the preliminary work and options proposed by the UNICEF health financing consultant and take into consideration UNHCR’s requirements for its persons of concern.
Costing of essential PHC package: determine the costs of expanding the Thrive package to a comprehensive package for refugees to include over 5s, adults, NCD and mental health care.
Funding and Financing Options for Hospital Care: review of financing options for hospital care including private sector insurance schemes, ‘Mutuel’ funds and trust funds.
Essential Minimum qualifications and competencies;
§ Health or social sciences graduate, including economics, statistics, public health and similar.
At least twelve years of experience in analysing health systems, financing of health systems, cost modelling and health sector policy development in low and middle income settings including UN experience.
§ Familiarity with the Universal Health Coverage concept and inclusion of vulnerable / poor/ hard-to-reach populations in national health systems.
§ Knowledge and understanding of complex privatised health care systems.
§ Strong analytical thinker and innovator.
§ Fluent in English, with Arabic an additional asset.
Desirable qualifications and competencies;
§ Master Degree in health policy, public health, health financing or similar areas of work.
§ Working experience in the Middle East.
§ Experience in working with refugee populations or humanitarian agencies.
§ Consultancy will be a total of 12 weeks.
How to apply:
Please send applications to hqphn@unhcr.org